Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
The Health Center Program Application Forms Modified 1034 2068 0 Form 0285-1b Funding Request Summary
The Health Center Program Application Forms New 100 100 0 Form 0285-Delete Services CIS_Delete Services Checklist
The Health Center Program Application Forms Modified 1034 2068 0 Form 0285-2 Staffing Profile
The Health Center Program Application Forms Modified 1034 5170 0 Form 0285-3 Income Analysis Form
The Health Center Program Application Forms Modified 1034 1034 0 Form 0285-4 Community Characteristics
The Health Center Program Application Forms Modified 1034 1034 0 Form 0285-5a Services Provided
The Health Center Program Application Forms Modified 1034 1034 0 Form 0285-5b Service Sites Listing
The Health Center Program Application Forms Modified 700 350 0 Form 0285-5c Other Activities
The Health Center Program Application Forms Modified 1034 1034 0 Form 0285-6a Board Member Characteristics
The Health Center Program Application Forms Modified 150 150 0 Form 0285-6b Request for Waiver of Governance Requirements
The Health Center Program Application Forms Modified 1034 2068 0 Form 0285- HC Plan- BPR Health Care Plan- Non Competing
The Health Center Program Application Forms Modified 250 250 0 Form 0285-8 Health Center Affiliation Certification
The Health Center Program Application Forms Modified 900 2700 0 Instruction
Form 0285-9 Need for Assistance
The Health Center Program Application Forms Modified 1034 1034 0 Form 0285-10 Annual Emergency Preparedness
The Health Center Program Application Forms Modified 800 3200 0 Form 0285-HC Plan-SAC NAP Health Care Plan- Competing
The Health Center Program Application Forms Modified 800 400 0 Form 0285-12 Points of Contact
The Health Center Program Application Forms New 800 3200 0 Form 0285-Business Plan-SAC NAP Business Plan- SAC NAP
The Health Center Program Application Forms New 1034 2068 0 Form 0285-Business Plan-BPR Business Plan- Non Competing
The Health Center Program Application Forms New 300 300 0 Form 0285-Add Site Checklist CIS Add Site Checklist
The Health Center Program Application Forms Modified 1034 2068 0 Form 0285-1a General Info Worksheet
The Health Center Program Application Forms Modified 250 625 0 Form 0285-1a Planning Grant-General Info Worksheet
The Health Center Program Application Forms New 700 700 0 Form 0285-Proposal Cover Pg Capital Improvement_Investment Proposal Cover Page
The Health Center Program Application Forms New 700 700 0 Form 0285-Project Cover Capital Improvement_Investment Project Cover
The Health Center Program Application Forms New 700 350 0 Form 0285-Project Impact Capital Improvement_Investment Project Impact
The Health Center Program Application Forms New 900 450 0 Form 0285- Assurances Assurances
The Health Center Program Application Forms New 900 900 0 Form 0285-Equipment list Equipment List
The Health Center Program Application Forms New 900 450 0 Form 0285-Other Reqs Other Requirements for Sites
The Health Center Program Application Forms New 200 200 0 Form 0285-Delete Site Checklist CIS Delete Site Checklist
The Health Center Program Application Forms New 200 300 0 Form 0285-Relocate Site CIS-Relocation Site Checklist
The Health Center Program Application Forms New 100 100 0 Form 0285-Add Services CIS_Add Services Checklist
The Health Center Program Application Forms Modified 1034 1034 0 Form 0285-4 Documents on File
Total burden requested under this ICR: 22758 37139 0  
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